High hopes for cocaine

Tools

The DaTscan lights up parts of the brain, enabling easier evaluation of neurodegenerative disorders.

If you hear "cocaine" and think of junkies smoking crack in squalid apartments, or of downward-spiraling rock stars, this may come as a shocker.

A cocaine-based drug is being used in doctors' offices around the world, including one large Pikes Peak area practice. And it's helping a lot of sick people.

The drug's medical re-emergence has been a cautious one. (And it is a re-emergence, as cocaine was used as a painkiller and treatment option for everything from toothaches to wound-healing until around the turn of the 20th century.) This is no medical marijuana. Nor does the situation resemble that of the club drug ketamine, now seen as a promising treatment for depression.

Instead, doctors are using extremely small doses of radioactive cocaine analogue to "light up" dopamine receptors in patients' brains, allowing for easier diagnosis of Parkinson's disease.

At Colorado Springs Health Partners, the only city practice using the newly approved DaTscan test, doctors like radiologist Pio Hocate and neurologist Brian Grabert say they're helping patients get treatment faster, and prolonging their lives. The test is also helping them rule out the serious neurodegenerative disease for others. But, because of modern drug laws, the DaTscan has met with challenges with the U.S. Drug Enforcement Agency.

"We've had to go through a lot of hoops," Hocate notes.

Motor trends

Hocate and Grabert bend over a computer screen, where orange-and-black images of brains look like a Halloweenish Andy Warhol work.

"That's abnormal; that's normal," Grabert says, pointing at two scans, one more lit-up than the other.

Grabert, who's been in practice since 1980, explains that when people develop Parkinson's — probably most widely known for affecting actor Michael J. Fox — they stop producing a normal level of the neurotransmitter dopamine. Most of us know dopamine as something that makes us feel good, and wards off depression. But dopamine is also the main chemical that charges our motor system.

A new Parkinson's patient produces about 70 percent less dopamine than the average person, leading to motor problems and, at times, dementia. People often live for 20 years with the disease before dying of a complication, like a fall or infection.

Early on, the National Parkinson's Foundation notes, patients show as many as four telltale symptoms: a tremor, slowness of movement, stiffness and trouble with balance.

Doctors once had to diagnose Parkinson's based on these symptoms alone, a tricky business since other diseases and abnormalities like harmless "essential tremor" or the beginnings of dementia often mimic Parkinson's. Usually, doctors who suspect Parkinson's put patients on treatment with drugs that mimic dopamine in their bodies. If symptoms subside, the patient is assumed to have Parkinson's.

The method usually works, but not always. Some Parkinson's patients don't respond well to medication; others who don't have Parkinson's may seem to improve with the drugs.

"The diagnosis of Parkinson's is not always 100 percent accurate on a clinical basis," Grabert says. "In fact, much less than that."

The DaTscan was meant to help people who stump neurologists, Hocate says, by ruling out many conditions that present like Parkinson's. "It's really a problem-solving tool," he explains.

For the DaTscan, a patient is injected with iodine and the radioactive cocaine analogue mixture, then scanned. The cocaine lights up the caudate and putamen, parts of the brain that contain the neurotransmitters for dopamine. In a normal scan, these two parts look like twin commas; in a person with Parkinson's, they often look more like periods.

Change agents

In January 2011, GE Healthcare's DaTscan (generically called Ioflupane I 123 Injection) became the first U.S. Food and Drug Administration-approved diagnostic imaging agent to help doctors evaluate neurodegenerative movement disorders like Parkinson's.

It was a breakthrough, and pioneering practices began seeking approval from the DEA to use it. Since roughly 1 percent of people over 65 will get Parkinson's (plus a small number of younger people), it looked likely that large offices in large- to mid-sized cities could make use of the technology.

CSHP, which with 10 locations is the largest physician-owned, multi-specialty practice in the state, applied to carry the drug early in 2012. But it took five months to get approval, despite the DaTscan using so little cocaine that it can't get a person high.

Over those five months, Grabert estimates, he had as many as 12 patients on whom he would have liked to use the test. Since being approved to carry the DaTscan in September, CSHP has tested five patients. All but one had Parkinson's, and it's notable that the odd man out was about to go into surgery for Parkinson's, during which he would have had deep brain stimulation. That involves hooking a "brain pacemaker" onto the brain, and shooting it with electrical signals.

"If you don't need that..." Hocate says with a laugh.

So far, the doctors note that their patients' various insurance companies have covered the $2,500 test for patients. But even if underinsured or uninsured, Parkinson's patients referred by a neurologist may want to take the test. Parkinson's medications can cost a bundle — Grabert knows one of the drugs is $900 out-of-pocket a month — and, of course, they won't work for a non-Parkinson's patient. Plus, a patient may have a different condition that could be helped with early treatment.

Says Hocate, who's been in practice since 2001: "You don't want to be treated for something you don't have."